New HIPAA Compliance Audit Program – The New Audit Protocol and How It Affects you

Fremont

10/15/2019

10:00am - 11:30am

Overview:

In this session we will discuss the HIPAA audit and enforcement programs and how they work, and discuss the areas that caused the most issues in prior audits. We will explore what kind of issues and what kind of entities had the most problems, and show where entities need to improve their compliance the most.

We will also explore the typical risk issues that lead to breaches of health information and see how those issues may be a target for auditors in the next round of audits.

We will review the contents of the HIPAA Audit Protocol used in 2016 to show what documentation needs to be on hand should your organization be selected for an audit in the new round.We will present methods for using the contents of the HIPAA Audit Protocol to build your own compliance plan by extracting and updating the contents and relating your compliance activities directly to the questions that might be asked.

In this session we will discuss the HIPAA audit and enforcement regulations and processes, and how they apply to HIPAA covered entities and business associates.We will explain the enforcement regulations and the new, increased fines and new penalty levels, including new penalties for willful neglect of compliance that begin at $10,000.

We will discuss what information and documentation must be prepared in advance so that you can be ready for an audit at any time, including sample information request forms and questions asked at prior audits. The session will also cover how to know if you may become the subject of an audit or enforcement action, and what you can do to help limit your exposure.We will discuss how most enforcement actions come about and what can be done to prevent incidents that lead to enforcement activity.

The HIPAA Privacy,Security, and Breach Notification regulations (and the recent changes to them) and how they will be audited will be explained. Documentation requirements for compliance will be explored and a framework of security policies necessary for compliance will be presented. The HIPAA Audit Protocol questions will be explored and ways of using the content to develop a compliance plan will be discussed. The process of exporting the questions will be shown, and a sample spreadsheet showing the results will be presented.

The results of prior HHS audits and enforcement actions (and their penalties) will be discussed, including recent actions involving multi-million dollar fines and settlements.A plan for attaining compliance will be presented. The steps to follow to prepare for an audit and respond to an audit request will be outlined.

Why Should you Attend: HIPAA Compliance requires that you be prepared to handle Protected Health Information properly and follow the requirements in the HIPAA Privacy, Security, and Breach Notification Rules. If there is a problem that comes to the surface, an enforcement action can result, including financial settlements that can reach into the millions of dollars, and Corrective Action Plans that can take years to complete and can cost many times the expense of the monetary settlements.

HIPAA enforcement and audits are now a significant reality, and settlements for violations are being announced more and more frequently. Now, with the increases in breach reporting and the new random audit program under way, enforcement of HIPAA is something that every HIPAA entity and business associate needs to be aware of and prepared for, by taking the proper steps in advance to have your compliance in order and the documentation to prove it.

Knowing what questions are likely to be asked and what documentation is necessary to show compliance are key to preparations for HIPAA compliance inquiries, and this session will explore a number of sets of questions and the issues they revealed, leading to enforcement action.

Every entity under the HIPAA regulations needs to know why the enforcement actions took place and what could have been done differently to prevent the violations that led to enforcement, so they can avoid those issues and their significant impact. Failure to do so can lead to financial settlements, fines, and/or corrective action plans that can severely impact your organization.

Areas Covered in the Session:

Learn how to make the HIPAA Audit Protocol useful to you as a way to organize and track your compliance work, and collect your documentation references
Find out what you’ll need to have documented to survive an audit or compliance review and avoid fines
Learn how to use an information security management process to evaluate risks and make decisions about how best to protect PHI and meet patient needs and desires
Find out what policies and procedures you should have in place
Learn about the training and education that must take place and be documented to ensure your staff uses health information properly and does not risk exposure of PHI
Find out the steps that must be followed in the event of a breach of PHI
Learn about how the HIPAA audit and enforcement activities are now being increased and how you must be prepared or risk significant penalties

Sheldon-Dean serves on the HIMSS Information Systems Security Workgroup, has co-chaired the Workgroup for Electronic Data Interchange Privacy and Security Workgroup, and is a recipient of the WEDI 2011 Award of Merit. He is a frequent speaker regarding HIPAA and information privacy and security compliance issues at seminars and conferences, including speaking engagements at numerous regional and national healthcare association conferences and conventions and the annual NIST/OCR HIPAA Security Conference in Washington, D.C.